Transcript Request Form

Transcript Request Form
• Processing time for transcripts & certificates is 3 to 5 business days

• Transcripts are $3 per copy due with request

• Certificates are $5 per copy due with request

• All tuition/fees must be paid in full
Full Legal Name:*

First NameMiddle NameLast Name
Maiden Name:
Last Name
Last 4 digits of SSN*
Birthdate*

MonthDayYear
Date
I am requesting this transcript for:*

High school creditPersonal record of certificate courses completed
If you are a current high school student enrolled in a public school your BTECH high school credit will be reflected on your home high school transcript. Contact your home high school for more information. You do not need to complete this transcript request.

If you are a homeschool or out-of-state student, continue with the request.
Email:*
example@example.com
Phone Number:*
Please enter a valid phone number.
Approximate dates attended: *
Did you attend in:*

LoganBrigham
Have you received/requested a transcript from BTECH before?*

YesNo
Are you a former/current LPN (Practical Nursing) student?*

YesNo
LPN applicant?*

YesNo
Delivery Method:*

Mail to HomePick up from BTECHE-mail (unofficial transcripts only)Mail to Other School/Business (provide information below)Fax (provide information below)
School Name or Business Name*
Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Authorized person to pick-up transcript.
Will need picture ID at time of pick-up.
Email
If different from the one entered above.
Fax - : (Institution name, attention to, fax number, etc.) - Unofficial ONLY
Need an additional address?

YesNo
Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Comments:

Request is For:*

Official transcript Enter description

$3.00 Quantity

Unofficial TranscriptEnter description

$ Free Quantity

CertficateEnter description

$5.00 Quantity

Total

$0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

RELEASE ACKNOWLEDGEMENT: I authorize the release of my academic records to the third parties specified on this form. I also approve the delivery method indicated above.
Signature:*

Clear
Date:*

MonthDayYear
Date
How would you like to be notified?*

Please e-mail me when my transcript is ready or sentPlease call me when transcript is ready to be picked up
Should be Empty:

Transcript Request Form

RELEASE ACKNOWLEDGEMENT: I authorize the release of my academic records to the third parties specified on this form. I also approve the delivery method indicated above.